1115 waiver proposal will expand coverage to about 10,000 people

How to apply

Who is eligible

Coverage is available for pregnant women with incomes up to 139% of poverty, children with incomes up to 200% of poverty, and parents with incomes up to 51% of poverty. Utah’s guidelines also provide for other groups to obtain coverage depending on circumstances.

Limited expansion, pending CMS approval

In March 2016, Utah Governor Gary Herbert signed HB437 into law, providing for a limited version of Medicaid expansion. Utah House Majority Leader Jim Dunnigan noted that the legislation “targets those in extreme poverty” so it’s much less comprehensive than the Medicaid expansion called for in the ACA.

Instead of expanding coverage to 126,000 people (as would be the case if the state were to accept federal funding for the ACA’s version of Medicaid expansion), HB437 expands coverage to about 9,000 – 11,000 of Utah’s poorest residents. The limited expansion provides Medicaid for 12 months to people who are homeless, mentally ill, in need of treatment for substance abuse, or recently released from incarceration.

Utah’s limited expansion of Medicaid will cost the state about $30 million a year ($13.6 million of that will come from hospitals in the state), and the federal government will pay about $70 million a year. Democratic lawmakers — who feel that HB437 is “less than crumbs” — note that full expansion of Medicaid would have cost the state $44 million a year (some estimates say $50 million), but would have brought in $420 million a year in federal funds, garnering far more value from those state dollars.

Utah submitted a Section 1115 waiver proposal to CMS in July, but CMS quickly responded, asking for additional information and an additional public comment period. The state is planning to implement the limited Medicaid expansion proposal in January 2017, assuming CMS approves the waiver.

Democratic gubernatorial challenger supports Medicaid expansion

According to Ballotpedia, however, Herbert’s seat is considered very safe. Herbert has done more to push for some sort of Medicaid expansion than many of his fellow Republican governors around the country, and it’s unlikely that he’ll be replaced in 2016 by a governor willing to push harder for Medicaid expansion.

House Republicans rejected expansion compromise

In October 2015, House Republicans overwhelmingly rejected the state’s latest proposal to expand Medicaid to cover residents with household income up to 138 percent of poverty (a little over $33,000 for a family of four).

Just seven out of 63 Republicans in the Utah House of Representatives supported the Utah Access Plus proposal in a closed-door meeting to determine whether the measure had enough support to pass. Support from at least 38 Republicans was needed to keep it alive, as long-standing Republican House Caucus rules in Utah require enough Republican votes to reach the majority without counting votes from Democrats. Ultimately, it would not have mattered even if votes from Democrats had been considered, since that would have brought the total to at most 19 Representatives in support of Utah Access Plus – still well short of half the chamber.

Much of the debate over Utah Access Plus had to do with funding. Utah needed to generate about $50 million in order to cover the state’s portion of the cost of expanding Medicaid (the federal government funds the full cost through 2016, but after that, the state’s share gradually rises to 10 percent). Utah Access Plus relied on fees spread across the state’s medical providers and stakeholders, including hospitals, doctors, and managed care plans. A public hearing on the proposal in early October drew significant criticism from healthcare providers who worried about the impact of the fees, particularly the fact that they could grow over time. For physicians, the fee was initially to be $67 per month.

The House’s rejection of Utah Access Plus effectively put Utah back at the drawing board in terms of Medicaid expansion. If lawmakers do not approve some sort of Medicaid expansion, they will miss out on $5.3 billion in federal funding by 2022. And until Medicaid is expanded, at least 41,000 (many estimates say more than 60,000) Utah residents remain in the coverage gap – ineligible for Medicaid and also ineligible for premium subsidies in the exchange.

What was Utah Access Plus?

Utah Access Plus was a compromise proposal reached by Utah’s “gang of six” earlier in 2015, after lawmakers rejected Governor Herbert’s Healthy Utah Medicaid expansion proposal during the 2015 legislative session. If it had won legislative support, Utah Access Plus would have used Medicaid funds to purchase private coverage for eligible residents. Because it was an alternative method of expanding Medicaid, it would have also needed HHS approval in order to obtain federal funding.

The “gang of six” included Governor Gary Herbert, Lt. Governor Spencer Cox, Senate President Wayne Niederhauser, House Speaker Greg Hughes, House Majority Leader Jim Dunnigan and Senator Brian Shiozawa. They worked together during the summer of 2015 to flesh out the details of a plan to replace two previous proposals (Gov. Herbert’s Healthy Utah plan and the House of Representatives’ Utah Cares plan). The gang of six announced in July 2015 that they had come to an agreement on a path to Medicaid expansion, but as of October, they were back to square one.

Prior rejection

Governor Gary Herbert has been working for years to expand Medicaid. The House’s failure to support Utah Access Plus was the second time he’s offered a proposal to lawmakers only to see it rejected. In October 2014, Herbert announced that he had come to a tentative agreement with HHS on his Healthy Utah plan that would have offered a modified, somewhat unique approach to expansion.

Governor Herbert unveiled the details of the HHS-approved Healthy Utah program at a meeting with legislators in December 2014. The proposal would have covered 126,000 Utah residents, but the legislation to implement it, SB 164, failed in committee in March 2015. Lawmakers in the House Business and Labor Committee instead voted to recommend the Utah Cares proposal (HB 446) for further consideration. Utah Cares would have cost the state more, garnered less in federal funding, and covered fewer people with much more limited benefits. It had also not received tentative approval from HHS the way Herbert’s Healthy Utah plan had. Ultimately, neither bill advanced in the legislature during the 2015 session.

Who is currently eligible for Medicaid in Utah?

Utah was among the states that initially implemented Medicaid in the first year it was available; their program became effective in July 1966. But existing Medicaid coverage is mainly limited to children and those who are elderly, disabled, or pregnant, as well as women with breast or cervical cancer and very low-income parents.

Pregnant women with household income up to 139 percent of poverty. The mother receives full Medicaid coverage throughout the pregnancy and for 60 days postpartum.

Children with household incomes up to 139 percent of poverty (CHIP is available to children with household incomes up to 200 percent of poverty).

Women with household incomes up to 250 percent of poverty are eligible for certain cancer screenings through the Utah Cancer Control Program (UCCP). If they are found to have breast or cervical cancer during the screening, they are eligible for full Medicaid coverage. If they have a precancerous condition (breast or cervical), they are eligible for three months of Medicaid.

Parents with dependent children can get Medicaid coverage if their household income is under 44 percent of poverty (if the state’s demonstration waiver based on HB437 is approved by CMS, eligibility would expand to 55 percent of the poverty level)

Utah provides Medicaid for various other select populations – check their list to see if you might be in any of the eligible groups.

How do I enroll?

You can enroll by phone at 1-800-318-2596 (HealthCare.gov phone application)

You can print a paper application (available in English and Spanish) and submit it by mail or fax (addresses and fax number here).

You can apply in-person at your local Department of Workforce Services office (click here to see a map and find your local office).

Small enrollment growth

From 2013 to July 2016, total enrollment in Utah’s Medicaid program increased by 4 percent (12,828 people). Although eligibility guidelines are unchanged from 2013, some people who were already eligible under the existing rules have enrolled since 2013.

How will expanding Medicaid help Utah?

The Kaiser Family Foundation estimates that 41,000 people are still in the coverage gap in Utah, unable to qualify for Medicaid and also ineligible for exchange subsidies to help them purchase private insurance [this is a significant reduction from KFF’s 2014 estimate (although it’s higher than their 2015 estimate), and it’s also significantly lower than the 77,000 people that the University of Utah has estimated are in the coverage gap in Utah. But Andrew Sprung has calculated the coverage gap in Utah by extrapolating based on the nationwide data, and he came up with 34,000 people; regardless of which number is correct, there are tens of thousands of people in Utah who have no realistic access to health insurance]. Subsidies in the exchange are only available to people with household incomes between 100 percent and 400 percent of poverty level, because Congress had intended for Medicaid to be available to everyone under the poverty level.

According to Gallup data, Utah’s uninsured rate dropped only slightly from 2013 to 2014, from 15.6 percent to 13.3 percent, and showed almost no change at all in the first half of 2015, holding nearly steady at 13.2 percent. But by the end of 2015, it had dropped to 12.4 percent. US census data put the state’s uninsured rate at 14 percent in 2013, and 12.5 percent in 2014. Extending Medicaid coverage to the state’s poorest residents would help to make a much larger dent in the uninsured rate.

Healthy Utah supporters estimated that 126,000 people in the state would be newly-eligible for Medicaid coverage if the state expands coverage up to 138 percent of the poverty level. Many of them are currently eligible for subsidies to purchase coverage in the exchange, because their income is between 100 percent and 138 percent of the poverty level. But they would have significantly lower out-of-pocket expenses with Medicaid.

High public support for Medicaid expansion

A poll conducted in June 2014 found overwhelming public support in Utah for Governor Herbert’s Healthy Utah plan. 88 percent of respondents favored the Governor’s approach over doing nothing, and 70 percent preferred it to standard Medicaid expansion as outlined in the ACA.

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